When Hospital Paperwork Crowds Out Hospital Care

By Theresa Brown

Dec. 19, 2015

A FRIEND was recently hospitalized after a bicycle accident. At one point a nursing student, together with a more senior nurse, rolled a computer on wheels into the room and asked my friend to rate her pain on a scale of 1 to 10.

She mumbled, “4 to 5.” The student put 5 into the computer — and then they left, without further inquiring about, or relieving, my friend’s pain.

This is not an anecdote about nurses not doing their jobs; it’s an illustration of what our jobs have become in the age of electronic health records. Computer documentation in health care is notoriously inefficient and unwieldy, but an even more serious problem is that it has morphed into more than an account of our work; it has replaced the work itself.

Our charting, rather than our care, is increasingly what we are evaluated on. When my hospital switched to bar code scanning for medication administration, not only were the nurses on my floor rated as “red,” “yellow” or “green” based on the percentage of meds we scanned, but those ratings were prominently and openly displayed on printouts left at the nurses’ station.

Or consider “fall assessments,” which a nurse uses to determine a patient’s risk of falling while in the hospital — a problem that accounts for 11,000 deaths annually. The assessments ask about medication, mobility issues and confusion to create a “fall risk score,” which then generates an appropriate menu of interventions.

A nurse could spend 10 minutes documenting a patient’s fall risk, or 10 minutes trying to keep patients from falling. It seems obvious that a computer record of “fall risk” cannot in and of itself prevent falls, but completing those records is considered essential in hospitals. As a result, real fall-prevention efforts — encouraging patients to use the call light, ordering a bedside commode, having an aide do hourly check-ins — get short shrift.

In home hospice, where I now work, the documentation is even more onerous than in the hospital and seems even more disconnected from actual patients. Hospice care is a covered benefit under Medicare, and the Centers for Medicare and Medicaid Services maintain rigid standards for documentation. They regularly withhold reimbursement if documentation is deemed incomplete or flawed.

This paperwork may have a good intent — to prevent fraud — but in practice it gives documentary exactitude an outsize importance. A colleague doing a hospice admission wrote that a dying patient had “liver failure and renal failure,” and in a separate part of her documentation wrote the conditions in the reverse order: “renal failure and liver failure.” From a medical point of view, the order of the two is irrelevant, but her supervisor reprimanded her for the disparity, since it suggested inconsistency. The concern, of course, was that the hospice wouldn’t get paid.

Charting a hospice admission usually takes between two and four hours, and requires filling out a seemingly endless number of data fields — some of them defying logic. I once had an oxygen-dependent centenarian patient in heart failure seeking admission to hospice. The hospice physician asked for further proof that the patient met the strict standards for hospice admission. It was a weekend, and during the time it took for me to collect that information, the patient died.

The worst, though, are the health risk assessments done for patients in Medicare Advantage, a program that pays for their coverage under certain private insurance plans. These assessments include an exam, an accurate health history, and diagnosis and documentation of the most serious possible version of the patient’s illnesses. This is known as diagnosis “capture,” and the entire process is colloquially referred to as “upcoding.”

Because upcoding classifies these patients as higher risk medically, Medicare increases the reimbursement given to their insurance companies without requiring that patients’ new, more severe diagnoses be treated in any way. Independent companies exist to do these evaluations, and according to an exposé published by the Center for Public Integrity in 2014, they cost our government billions of dollars every year.

The importance of accurate medical histories for very ill patients can’t be argued, and records are often surprisingly incomplete, so there is clinical value to this highly lucrative paperwork. But it seems equally inarguable that health care reimbursements should in general be tied to actual care given to actual people, and not to documentation alone.

Electronic health records present an enticingly clean and clear vision of clinical work, whereas real patients — their histories, their bodies — are messy, confusing and unpredictable. Sadly, all the attention given to our paperwork is taking us further and further away from the difficult truth that meeting very ill patients’ needs occurs in real time with real people, not in the paperwork about them.

We need to streamline our records so that they serve just one master: the patient. We should focus on the most important information in guaranteeing accuracy of diagnosis, efficacy of treatment, continuity of care and patient safety. Otherwise the content of our care will be increasingly warped by the demands of our e-record systems — and patients like my poor friend will lie in hospital beds in pain, uncomforted by the knowledge that the electronic record of that pain is satisfyingly and exactingly complete.

Theresa Brown is a registered nurse and the author of “The Shift: One Nurse, Twelve Hours, Four Patients’ Lives.”